MEDICARE: DR. TARA L. SULLIVAN O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	5072	MA

General Provider Information

NPI Number	:	1518410133
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TARA L. SULLIVAN O.D.

Provider Business Mailing Address
First Line	:	475 LISBON ST
Second Line	:
City	:	LEWISTON
State	:	ME
Zip	:	04240-7418
Country	:	US
Telephone Number	:	207-786-2500
Fax Number	:	207-786-2503

Provider Business Practice Location Address
First Line	:	245 CENTER ST
Second Line	:
City	:	AUBURN
State	:	ME
Zip	:	04210-6169
Country	:	US
Telephone Number	:	207-786-2500
Fax Number	:	207-786-2503

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2016
Last Update Date	:	07/26/2023

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